ST11843 1PLY UB-92 1 12 PATIENT NAME ADMISSION 17 DATE 18 HR 2 6 STATEMENT COVERS PERIOD FROM THROUGH 3 PATIENT CONTROL NO. APPROVED OMB NO. 0938-0279 4 TYPE OF BILL 5 FED. TAX NO. 7 COV D. 8 N-C D. 9 C-I D. 10 L-R D. 11 13 PATIENT ADDRESS CONDITION CODES 24 25 26 27 28 29 30 14 BIRTHDATE 32 CODE 15 SEX 16 MS 33 19 TYPE 20 SRC 21 D HR 22 STAT 23 MEDICAL RECORD NO. 31 OCCURRENCE DATE CODE OCCURRENCE DATE 34 CODE OCCURRENCE DATE 35 CODE OCCURRENCE DATE 36 CODE OCCURRENCE SPAN FROM THROUGH a b 38 39 CODE 37 A B C 40 CODE A B C VALUE CODES AMOUNT VALUE CODES AMOUNT 41 CODE VALUE CODES AMOUNT 42 REV. CD. 43 DESCRIPTION a b c d 44 HCPCS / RATES 45 SERV. DATE 46 SERV. UNITS a b c d 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 50 PAYER 51 PROVIDER NO. 52 REL INFO 53 ASG BEN 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 A B C 57 58 INSURED'S NAME DUE FROM PATIENT 59 P. REL 60 CERT. - SSN - HIC. - ID NO. 61 GROUP NAME 62 INSURANCE GROUP NO. A B C 63 TREATMENT AUTHORIZATION CODES 64 ESC 65 EMPLOYER NAME 66 EMPLOYER LOCATION A B C A B C 67 PRIN. DIAG. CD. 79 P.C. 80 68 CODE 69 CODE 70 CODE OTHER DIAG. CODES 71 CODE 72 CODE 73 CODE 74 CODE 75 CODE A B C 76 ADM. DIAG. CD. 77 E-CODE 78 CODE PRINCIPAL PROCEDURE DATE 81 CODE OTHER PROCEDURE DATE CODE OTHER PROCEDURE DATE 82 ATTENDING PHYS. ID A CODE B DATE CODE OTHER PROCEDURE DATE CODE OTHER PROCEDURE OTHER PROCEDURE DATE 83 OTHER PHYS. ID OTHER PHYS. ID C a 84 REMARKS b c d UB-92 HCFA-1450 D E 85 PROVIDER REPRESENTATIVE A B 86 DATE a b a b x OCR/ORIGINAL American LegalNet, Inc. www.FormsWorkflow.com I CERTIFY THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF. UNIFORM BILL: NOTICE: ANYONE WHO MISREPRESENTS OR FALSIFIES ESSENTIAL INFORMATION REQUESTED BY THIS FORM MAY UPON CONVICTION BE SUBJECT TO FINE AND IMPRISONMENT UNDER FEDERAL AND/OR STATE LAW. 9.For CHAMPUS purposes: This is to certify that: (a) the information submitted as part of this claim is true, accurate and complete, and, the services shown on this form were medically indicated and necessary for the health of the patient; (b) the patient has represented that by a reported residential address outside a military treatment center catchment area he or she does not live within a catchment area of a U.S. military or U.S. Public Health Service medical facility, or if the patient resides within a catchment area of such a facility, a copy of a Non-Availability Statement (DD Form 1251) is on file, or the physician has certified to a medical emergency in any assistance where a copy of a Non-Availability Statement is not on file; (c) the patient or the patient's parent or guardian has responded directly to the provider's request to identify all health insurance coverages, and that all such coverages are identified on the face the claim except those that are exclusively supplemental payments to CHAMPUSdetermined benefits; (d) the amount billed to CHAMPUS has been billed after all such coverages have been billed and paid, excluding Medicaid, and the amount billed to CHAMPUS is that remaining claimed against CHAMPUS benefits; (e) the beneficiary's cost share has not been waived by consent or failure to exercise generally accepted billing and collection efforts; and, (f) any hospital-based physician under contract, the cost of whose services are allocated in the charges included in this bill, is not an employee or member of the Uniformed Services. For purposes of this certification, an employee of the Uniformed Services is an employee, appointed in civil service (refer to 5 USC 2105), including part-time or intermittent but excluding contract surgeons or other personnel employed by the Uniformed Services through personal service contracts. Similarly, member of the Uniformed Services does not apply to reserve members of the Uniformed Services not on active duty. (g) based on the Consolidated Omnibus Budget Reconciliation Act of 1986, all providers participating in Medicare must also participate in CHAMPUS for inpatient hospital services provided pursuant to admissions to hospitals occurring on or after January 1, 1987. (h) if CHAMPUS benefits are to be paid in a participating status, I agree to submit this claim to the appropriate CHAMPUS claims processor as a participating provider. I agree to accept the CHAMPUSdetermined reasonable charge as the total charge for the medical services or supplies listed on the claim form. I will accept the CHAMPUS-determined reasonable charge even if it is less than the billed amount, and also agree to accept the amount paid by CHAMPUS, combined with the cost-share amount and deductible amount, if any, paid by or on behalf of the patient as full payment for the listed medical services or supplies. I will make no attempt to collect from the patient (or his or her parent or guardian) amounts over the CHAMPUSdetermined reasonable charge. CHAMPUS will make any benefits payable directly to me, if I submit this claim as a participating provider. Certifications relevant to the Bill and Information Shown on the Face Hereof: Signatures on the face hereof incorporate the following certifications or verifications where pertinent to this Bill: 1. If third party benefits are indicated as being assigned or in participation status, on the face thereof, appropriate assignments by the insured/ beneficiary and signature of patient or parent or legal guardian covering authorization to release information are on file. Determinations as to the release of medical and financial information should be guided by the particular terms of the release forms that were executed by the patient or the patient's legal representative. The hospital agrees to save harmless, indemnify and defend any insurer who makes payment in reliance upon this certification, from and against any claim to the insurance proceeds when in fact no valid assignment of benefits to the hospital was made. 2. If patient occupied a private room or required private nursing for medical necessity, any required certifications are on file. 3. Physician's certifications and re-certifications, if required by contract or Federal regulations, are on file. 4. For Christian Science Sanitoriums, verifications and if necessary reverifications of the patient's need for sanitorium services are on file. 5. Signature of patient or his/her representative on certifications, authorization to release inform